2 Stop the Medicalisation of Old AgeMedical ageism…now includes over-investigation and subjecting frail elders to unpleasant, unnecessary, and unproved procedures and therapies.

3 Half of patients >75 years are taking more than four drugs Medication reviewHalf of patients >75 years are taking more than four drugsAssociated withFallsHip fracturesHospitalisationDeathFinancial costPracticalities

4 Efficacy and Safety in ElderlyPaucity of studies in elderlyTime to benefitAmount of benefitComplianceAdverse drug reactionsReduced ability to metaboliseor excrete drugs

5 What do patients want / expect from medication?EffectiveRelief of symptomsPrevention of disease / disabilitySafe – low incidence of adverse effectsEasy to takeAnd at the end of life the priority is usually symptom control

7 Potentially Inappropriate Prescription (PIP)A medication for which the potential harm outweighs the benefit and for which a suitable alternative is available

8 PIP in fallers attending A&E1016 patientsHalf required admission63% took more than four drugs42% had one or more PIP30% had received hypnosedatives in the preceding year17% were taking anxiolytics15% were prescribed antipsychoticsAge and Aging 2014;43:44-50

9 Inappropriate PrescriptionWrong indicationNo indicationInappropriate doseHigh risk of adverse eventOf unlikely benefitUnnecessarily expensiveToo short or too long a time periodUnder-prescribing

10 Evidence for Drug cessation at the end of lifeDiscontinuation of drugs aimed at prolonging or preventing clinical events with no symptomatic benefitVery little publishedRecent review article Tischa JM Age and Aging 2014;43:20-25Need to develop a consensus criteria for inappropriate prescriptions at the end of life

11 De-prescribing towards the end of lifeIn conjunction with patient / carerEstablishing prioritiesRelaxing targets for therapy such as BP and blood sugarsAvoid sense of hopelessness

12 Mark Beers, American Geriatrician 1991 Beers CriteriaMark Beers, American Geriatrician 1991Catalogue of potentially inappropriate medications for the elderly due to pharmacological properties and physiological changes in agingUpdated and evidence based 2012Based on US prescribing

21 Is the drug still needed? Has the condition changed? Questions to askIs the drug still needed?Has the condition changed?Can the patient continue to benefit?Has the evidence changed?Have the guidelines changed?Is the drug being used to treat an iatrogenic problem?What are the ethical issues about withholding care?Would discontinuation cause problems?Some therapies should not be stopped abruptly following long-term use.Stopping Medicines, WeMeReC 2010

22 Would I be surprised if this person were to die in the next 12 months? Boyd and Murray, 2010Would I be surprised if this person were to die in the next 12 months?Review goals of careRevision of treatments – particularly those for secondary preventionLimit investigations

23 Previously at home with qds care package Case StudyFrail 84 year old ladyPreviously at home with qds care packageBeing discharged to NH following admission with hip fracture and profound anaemiaRotunda transfers to recliner chairNeeds assistance with all ADLsDoubly incontinent